Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 9039 | MN |
NPI | 1003249616 |
---|---|
Provider Name | Lauren Stavenger |
First Address | Plymouth, MN 55441-6486 |
Second Address | Robbinsdale, MN 55422-2207 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2013 |
Last Update Date | 19/08/2013 |